SBM Little Application

Hidden Fields

Youth Contact Owner ID

Youth Contact ID

Youth Enrollment ID

Guardian Contact ID

IMPORTANT INFORMATION

REQUIRED: This form MUST be signed (e-signature) by the parent or legal guardian of the child being enrolled.

PLEASE NOTE: If this form is being completed with the assistance of another individual (not the parent or legal guardian) it is critical that the parent or legal guardian be present during it's completion to review all information provided and to review all conditions of consent included within this application.

Child's First Name:

Child's Last Name:

Prefers to be called:

Date of Birth:

Gender:

Ethnicity:

School:

Grade:

Teacher:

Parent/Guardian First Name:

Parent/Guardian Last Name:

Guardian's Relationship to Youth

Do you have legal custody?

YesNo

Parent/Guardian Email:

Home Address:

City:

State:

Zip Code:

County:

Does your child attend the Bangor Boys and Girls Club?

Is your mailing address different than your home address?

YesNo

Mailing Address:

City:

State:

Zip Code:

Home Phone:

Parent/Guardian Cell Phone:

Parent/Guardian Work Phone:

Please answer the following questions:

What is the youth's living situation?

Please explain:

Edit this text

Free/Reduced Lunch

What is your average annual income (family):

Do any of the following apply to your family?

Child of current/past incarcerated parentMilitary ParentNeither

Has the applicant had any prior involvement with the Juvenile Justice System?

YesNo

Please describe involvement:

What are the youth's interests and hobbies?

How might the child benefit from having a mentor?

Please describe the child's school performance and ability to get along with peers their age?

Does the child have any behavioral, emotional, or medical concerns or special considerations?

Transportation Information

Are you able to pick up your child after every match meeting?

YesNo

Are you able to arrange with another adult for consistent and reliable pick up?

YesNo

Please list below any adult you give consent to pick up your child. Individual must bring photo ID when they pick up your child.

Name:

Phone Number:

Relation to child:

Emergency Information

Child's Name:

Parent/Guardian Name:

Home Address:

Home Phone:

Cell Phone:

Person(s) to be contacted in emergency situations if parent/guardian is not reachable:

First Name:

Last Name:

Phone Number:

Relationship to Youth

School-Based Mentoring Parental Consent

By checking the box below, I give permission for my child (identity provided on the previous page), to participate in the Big Brothers Big Sisters of Mid-Maine (BBBSMM) School-Based Mentoring one day per week after school. In doing so I understand and agree to the following:

My child (Little) will meet with their (Big) one day per week, throughout the school year.
Bigs and Littles will be expected to participate in a Summer Pen Pal program in the summer months (i.e. post cards, letters, and/or emails).
The school guidance counselor may share information regarding my child with BBBSMM for the purpose of determining a suitable mentor and addressing child safety concerns as well as reporting on school attendance and overall performance.
For the school to provide social, academic, demographic and contact information about my child to Big Brothers Big Sisters (e.g. report cards, behavior reports, parent contact information etc);
All applicant information in regards to my child, including home address, will be kept confidential.
I am responsible for picking-up my child, or arranging transportation for my child, at the designated end time of match meeting.
BBBSMM does not guarantee my child will be matched and has discretion in creating and/or closing or a match in regards to child safety and the best interests of all parties involved.
I understand contact outside of school mentoring activities is not permitted.

By checking this box, I certify I have read the above information and provide my consent.

Media Release

Big Brothers Big Sisters of Mid-Maine creates media (brochures, press releases, annual appeal letters, BBBSMM website, social media, tv, radio spots, etc.) to highlight match successes and recruit volunteers. I understand my child's interaction with his/her match may be photographed/taped and possibly used for these agency purposes only.

I give permission for my child's photo being used in a specific media form, i.e.: on the website.I DO NOT give permission for my child's photo being used in a specific media form, i.e.: on the website.

Emergency Medical Consent

I, the parent/guardian of the child/youth for whom this application is being completed, consent to the performance of such emergency medical care upon my son/daughter, for whom this application is being completed, as may be deemed necessary or advisable in the judgment of the examining physician in the event I cannot be reached at the time of said emergency.

By checking this box, I give my consent.

TheApp

I consent to my child's use of TheApp, an online communication tool to help matches stay connected when they are not able to meet in person or to supplement in-person visits. TheApp is part of Big Brothers Big Sisters online data organization system; and all communication between Bigs and Littles is monitored by Agency Staff.

By checking this box, I give my consent.

Supporting Information

This application was completed with the support of an individual who is NOT the parent or legal guardian of the child enrolled.

YesNo

Name:

Role/Relationship:

Contact Information: